**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to provide treatments and services for two of two sampled residents (Residents 1 and 2) by failing to: 1. Ensure Resident 1's food allergy and allergic reaction to fish were transcribed and verified in the resident's Dietary Profile and Meal Ticket, in accordance with the facility's policy and procedure on Food Allergies and Reference Sheets, and Diet Record Maintenance to alert facility staff of the resident's food allergies. 2. Ensure Resident 1's care plan (a nursing care plan provides direction on the type of nursing care the individual may need) on food allergy was developed to include the type of allergic reaction manifested by the resident and implemented the care plan on food allergy (fish allergy) to ensure Resident 1 was free from allergic reaction. 3. Ensure Licensed Vocational Nurse (LVN) 3 communicated with the facility's Dietary Department by indicating Resident 1's fish allergy on the Diet Communication Slip upon Resident 1's admission to the facility on [DATE], as indicated in Resident 1's Order Summary Report and in accordance with the facility's policy and procedure titled Diet Orders. 4. Ensure the facility's Dietary Supervisor (DS) checked Resident 1's Allergy Report found in the resident's electronic records and General Acute Care Hospital (GACH) 1's History and Physical (H&P), during initial resident interviews. In addition, to check accuracy of the Dietary Communication Slip, the resident's Diet Type Report (a list of residents, their corresponding diets and other information such as allergies) and Meal Tickets, in accordance with the Dietary Supervisor's documented Job Description. 5. Ensure Resident 2's care plan on food allergies to eggs, milk and milk products, shrimp, wheat, beef, tomato, pork, orange juice was implemented. 6. Ensure the facility had a system in place for licensed nurses, certified nurse assistants, dietary supervisor, and kitchen staff to implement the facility's policy and procedure titled Food Allergies and Reference Sheets, to ensure the resident's entire care team (interdisciplinary team) is made aware of Residents 1 and 2's food allergies and its reaction. The facility was aware Resident 1 had fish allergy but Resident 1 was served fish on 11/24/2023 (tuna salad sandwich) and 12/1/2023 (lemon ginger fish). The facility was aware Resident 2 was allergic to wheat, but on 12/5/23, during a lunch tray line (an area used to dish out resident's food) observation, the kitchen staff served triple fruit crisp and garlic white bread that contained wheat, to Resident 2. As a result of these deficient practices, Resident 1 had an allergic reaction on 12/1/2023, after eating fish for lunch. Resident 1 had difficulty breathing and was observed with watery eyes and swollen face. The facility's licensed nurses called 911 emergency medical services (EMS), EMS intubated (healthcare provider inserts a tube through person's mouth or nose down to their airway) Resident 1 and administered three doses of epinephrine (used in emergencies to treat very serious allergic reactions). Resident 1 passed away upon arrival to the General Acute Care Hospital (GACH) 2 emergency room (ER) due to anaphylaxis (severe allergic reaction including closure of airways). This deficient practice had the potential to cause life-threatening conditions such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (heart stops beating suddenly) and death for Resident 2. On 12/5/2023 at 7 PM, while onsite at the facility, the Director of Nursing (DON) and the Administrator (ADM) were verbally notified of an Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) situation regarding the facility's failure to have a system in place for licensed nurses, certified nurse assistants, dietary supervisor, and kitchen staff to ensure the resident's entire care team (interdisciplinary team) is made aware of Residents 1 and 2's food allergies and its reaction. Resident 1, who was identified as having food allergies to fish was served fish on 11/24/2023 and 12/1/2023, that resulted to Resident 1's death. Resident 2, who was identified as having food allergy to wheat was served wheat on 12/1/2023. On 12/07/2023 at 7:13 PM, the IJ was removed in the presence of the ADM, DON, Registered Dietitian (RD) 1, Nursing Consultant 1 (NC 1) and NC 2 after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified and confirmed onsite the facility's implementation of the IJ Removal Plan. The accepted IJ Removal Plan indicated the following information: 1. Registered Dietitian (RD) 1 educated Resident 2 about avoiding food that she was allergic to minimize adverse reaction. RD 1 reviewed all resident's meals served on 12/6/2023 to ensure accuracy on meals served for breakfast prior to distribution of trays to the residents. RD 1 observed dietary staff during meal preparation on 12/6/2023 for breakfast, lunch, and dinner to ensure tray accuracy before the trays were served to the residents. RD 1 in-serviced nursing staff on 12/6/2023, about wheat allergy and wheat containing foods. 2. RD 1 conducted training with dietary staff on 12/6/2023, including aides and cooks regarding diet communication form processing, meal ticket creation, meal preparation following recipes and spreadsheet, tray line process and food allergies. RD 1 conducted interviews with all residents with food allergies and food preferences to ensure accuracy of allergies transcribed on the meal tickets based on Residents medical records. 3. The DON provided education to LVNs (Licensed Vocational Nurses) and Certified Nursing Assistants (CNA) on 12/6/2023, regarding food allergies, meal tray verification and tray accuracy. 4. The DON audited the Nutritional Care plans to ensure that allergies and allergic reactions of all residents with known allergies are entered in the care plans. 5. The DON provided in-service education to LVN 3 who admitted Resident 1 on 11/20/2023, regarding completion of dietary communication of diet orders and restrictions, allergies with the kitchen staff. The DON and DSD provided in-service on 12/1/2023 to LVNs regarding the process of communication of diet orders, restrictions, allergies to the kitchen. 7. The Regional Dietitian provided education on 12/4/2023, 12/5/2023 and 12/6/2023 to Cooks and Dietary Staff on the following: Diet Communication Form Processing, Meal ticket creation, meal preparation following the recipe and spreadsheet, tray line process and food allergies. 8. The Regional Dietitian updated Resident 2's Dietary Profile and care plan on 12/5/2023 for food preferences, food allergies and meal tray ticket. The Regional Dietitian reverified Resident 2's food allergies and updated Resident 2's meal tray ticket indicating the food allergies of Resident 2 according to the Dietary Profile. 9. Resident 2's physician placed an order for Resident 2 to obtain an allergy test determining allergy severity and reactions to wheat. The physician will notify Resident 2 and her family upon the receipt of the allergy test. 10. Licensed Nurses and RD 1 revised Resident 2's Nutritional Comprehensive Care Plan on 12/6/2023 based on Resident 2's dietary interview. 11. The facility designee conducted a meal tray verification learning validation testing on 12/7/2023 to the two LVNs and CNAs who verified Resident 2's meal tray on 12/5/2023. 12. The DON, designee and dietary manager reviewed and audited 99 current diet orders, allergies, tray cards on 12/1/2023 to ensure all dietary allergies were reflected on resident's records. 13. The DON and designee conducted rounds and observations of current residents and assessed if any residents were exhibiting signs and symptoms of allergic reactions. 14. The Regional Dietitian conducted a second audit of the diet orders, dietary profiles and meal ticket to ensure diet restrictions, preferences and food allergies are accurately entered in the system. No other residents were identified. 15. The DON reported to the attending physician of four (4) other residents who had no history or were unable to recall allergic reactions. Attending physician ordered an allergy test. The facility drew an allergy test on 12/6/2023 to the 4 residents. The attending physician will notify the resident and family of the allergy test. 16. The Regional Dietitian audited and observed the following on 12/6/2023 - Conducted skill competency validation to the dietary staff regarding transcription of dietary orders, restrictions, food preferences, and allergy information into the Resident Dietary System (RDS) to generate accurate meal tickets. - Observed dietary staff during the meal preparation for breakfast, lunch, and dinner. - Observed tray line service for breakfast, lunch, and dinner for tray accuracy prior to placing the meal trays in the meal cart. 17. The Regional Dietitian provided in-service education to nursing staff on wheat allergen and food to avoided. 18. The Regional Dietitian will orient, train, and conduct competency regarding dietary policies and procedures, diet communication from processing meal ticket, RDS system, meal preparation, tray line, food allergies, dietary profile, and care plan development once the Dietary Manager was hired. 19. The facility implemented of the new process on how to handle food allergy on 12/7/2023: The dietary manager will conduct an audit of current diet orders, diet order and communication forms, food allergies, meal tray ticket from the RDS system, dietary profile, and care plan weekly for 4 weeks then bi-monthly for 2 months to ensure accuracy of diet of residents. Cross Reference to F806 Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 11/20/2023, with diagnoses that included Type 2 diabetes mellitus (DM, a health condition when the body does not use insulin properly causing increase in blood sugar), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), and essential hypertension (high blood pressure). A review of Resident 1's Minimum Data Sheet (MDS, a standard assessment tool that measures health status), dated 11/27/2023, indicated the resident's cognition (a mental process that take place in the brain, including thinking, attention, language, learning, memory, and perception) was severely impaired. The MDS indicated Resident 1 needed partial/moderate (helper does less than half of the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort) assistance when eating. A review of Resident 1's physician diet order, dated 11/20/2023, indicated Resident 1's diet was No Added Salt (NAS, no salt packet on the tray) consistent carbohydrates (CCHO, the same amount of carbohydrate served each meal), regular texture, thin consistency. A review of Resident 1's GACH 1 History and Physical (H&P, details of physician examination of the resident), dated 11/10/2023, indicated, Resident 1's allergic reaction to fish was anaphylactic reaction. A review of Resident 1's Order Summary Report, for December 2023, signed by Physician 1 on 11/21/2023, indicated Allergies: fish. A review of Resident 1's Allergy Report printed by the facility with created date 11/20/2023 indicated Resident 1 had a food allergy and the allergy was Fish. The Allergy Report severity indicated unknown. The Allergy Report indicated blank on Reaction Manifestation and blank on Reaction Note. A review of a facility document titled Diet Communication Slip dated 11/20/2023, and signed by LVN 3, indicated Resident 1's name, room number, regular diet, no concentrated sweets, no added salt diet. The Allergies Section of the Diet Communication Slip was left blank. A review of Resident 1's care plan indicated that on 11/25/2023, a care plan was developed for Resident 1's food allergy, titled Resident allergic to fish and at risk for allergic reaction (4 days after the physician's order summary report indicating the resident was allergic to fish). The care plan indicated a goal for Resident 1 to be free of allergic reaction through the next review date. The care plan interventions included, to list all allergies in the resident's face sheet, have an allergy sticker on the chart, list allergies to medications, and treatment administration sheet. The care plan interventions also included to notify the physician for further change of condition or allergic reaction, and to administer antihistamine (a class of drugs commonly used to treat symptoms of allergies) as ordered. A review of the facility's fall menu spreadsheet dated 12/1/2023, approved by RD 2 on 8/17/2023 indicated, CCHO, NAS diet included the following food item on the tray: Lemon ginger fish 3 ounces (oz, a unit of measurement) A review of the facility's recipe titled Lemon-Ginger Fish not dated, indicated ingredients included: fish fillet, thawed (suggest tilapia, pangasius-swai, cod), ginger, jarred or ginger, ground, melted margarine, lemon juice and salt. A review of a physician's telephone order dated 12/01/2023 timed 12:30 PM, authored by the case manager (CM), indicated an order for Resident 1 to receive Epinephrine Injection kit 1 milligrams (mg/milliliter (ml) (a unit of measurement) inject 1 mg intramuscularly (under the muscle) one time only for anaphylaxis (a severe, potentially life-threatening allergic reaction). A review of Resident 1's progress notes from 11/07/2023 to 12/08/2023, with a note titled SBAR [Situation, Background, Assessment and Recommendations] Summary for Providers dated 12/01/2023 signed by Registered Nurse (RN) 1 timed at 12:30 PM, indicated, At 12:15 PM, Certified Nursing Assistant (CNA 1) served lunch plate to Resident 1. Around 12:25 PM, the resident called the CNA and complained of shortness of breath. CNA (CNA 1) called LVN (LVN 2), and he paged Registered Nurse 1 (RN 1) to assess Resident 1 around 12:26 PM. Resident 1 was assessed at 12:28 PM, Resident 1's Oxygen saturation (amount of oxygen circulating in the blood) was at 88% (normal oxygen saturation: 95 to 100%). RN 1 administered oxygen 2 liters via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen level) and elevated the resident's head of bed. Oxygen saturation was rechecked, and it was 91%. RN 1 asked Case Manager (CM) to call Resident 1's physician around 12:30 PM. (Physician 1) ordered epinephrine 1 mg via intramuscular (under the muscle) injection and to call 911 emergency service. LVN 1 was delegated to call 911 around 12:31 PM. Around 12:32 PM, epinephrine was administered to left thigh of Resident 1 but no effect. No vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body function) appreciated (found or noted) around 12:35 PM. CPR (cardiopulmonary resuscitation [an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped]) initiated and 911 (EMS) came around 12:38 PM and took over to continue CPR and resident was taken to (GACH 2) around 1 PM. A review of Resident 1's Fire Department Patient Care Report, dated 12/2/2023, timed at 1:03 PM, indicated Emergency Medical Services (EMS) was notified at 1:03 PM, EMS was dispatched at 1:04 PM, En route at 1:05 PM, and arrived at the facility at 1:07 PM. The Report indicated under EMS Narrative Resident 1 was found in bed pulseless (a condition where your heart stops), apneic (a temporary stop of breathing), pupils fixed/dilated (when the black circles in the colored part of the eyes [iris] gets larger, usually caused by brain damage/injury), unresponsive. The Report indicated that upon arrival the EMS arrival, they found facility staff performing CPR on Resident 1, for approximately 3 minutes. The Report indicated that according to facility staff, Resident 1 was Seen approximately 10 minutes before being found in full cardiac arrest, conversing and being alert and oriented times 3 (patient is alert and oriented to person, place and time). The Report indicated Per facility staff patient (Resident 1) had eaten lunch, which was a fish meal. Unknown if patient has any allergies to fish . A review of Resident 1's GACH 2 records dated 12/1/2023 titled ED Provider Notes authored by the ED Physician, indicated (Resident 1) was brought in from the (facility) where the resident was in cardiac arrest, CPR for 18 minutes. The ED Physician wrote that according to the paramedics, 3 (three) epinephrine were given and Resident 1 lost pulses and ED Physician immediately intubated Resident 1. The ED Physician wrote Resident 1 was given another epinephrine and CPR was continued until the ultrasound (an imaging method that uses sound waves to produce images of structures within the body) showed no heart movement at 1:53 PM. At 2:06 PM, Resident 1 was defibrillated (use of electrical current to help a person's heart return to normal rhythm) in the ED and there was no change in heart movement at 2:06 PM. The ED Physician wrote Diagnosis Death secondary to cardiac arrest with severe metabolic (a condition in which acids build up in the body) and respiratory acidosis (occurs when the blood is too acidic due to high levels of carbon dioxide [the gas formed when carbon is burned, or when people or animals breathe out). The ED Physician further wrote that he spoke to Resident 1's attending physician, Physician 1, who stated Resident 1 was allergic to fish and she was given fish. During an interview on 12/5/2023 at 9:15 AM, CNA 1 stated she worked on 12/1/2023 during the 7 AM to 3 PM shift and was assigned to Station 1 and to Resident 1. CNA 1 stated on 12/1/2023 at around 12:30 PM, she responded to Resident 1's call light and upon CNA 1's entrance to Resident 1's room, Resident 1 verbalized to her that she was having an allergic reaction to fish. CNA 1 stated, Resident 1 was exhibiting shortness of breath. CNA 1 stated she ran out of Resident 1's room to get the oxygen tank and informed LVNs 1 and 2, who both attended to Resident 1. CNA 1 stated the kitchen staff served fish that looked like tilapia to Resident 1 for lunch. CNA 1 stated Resident 1 ate the whole fish. CNA 1 stated, she was aware that Resident 1 was allergic to fish and seafood but unsure of the allergic reaction. CNA 1 could not recall who passed Resident 1's lunch tray on 12/1/2023. During an interview on 12/5/2023 at 10:46 AM, LVN 1 stated he worked on 12/1/2023 during the 7 AM to 3 PM shift as a desk nurse. LVN 1 stated he observed Resident 1 coughed, held her neck with swollen face, and had watery eyes. LVN 1 stated that Resident 1 stated she had a hard time breathing. LVN 1 further stated that LVN 2 checked the facility's electronic medical records for Resident 1's food allergy and the resident's records indicated Resident 1 was allergic to fish. LVN 1 stated he was aware Resident 1 was allergic to fish as he saw fish as food allergy indicated in the resident's Medication Administration Record (MAR, a record detailing the medications given to the residents by a healthcare professional). LVN 1 stated the fish came from Resident 1's lunch tray served by the facility's kitchen. LVN 1 stated RN 1 told the Case Manager (CM) to call Resident 1's physician (Physician 1). During an interview on 12/5/2023 at 3:44 PM, the DON stated according to her investigation, RN 1 and LVN 2 administered oxygen while Resident 1 was having shortness of breath. The DON stated Resident 1 ate fish that came from the facility's kitchen during lunch meal on 12/1/2023. The DON stated that based on their investigation, RN 1 and LVN 2 checked Resident 1's meal tray for accuracy and Resident 1's Meal Ticket did not indicate Resident 1 was allergic to fish. The DON stated the DS did not indicate Resident 1's allergy to fish on the resident's Meal Ticket. The DON stated the DS could not say if he checked Resident 1's electronic medical records to confirm. The DON stated Resident 1 passed away on 12/1/2023. During an interview on 12/5/2023 at 4 PM, the ADM stated that on 12/1/2023, he had witnessed Resident 1's change of condition (allergic reaction) around 12:15 PM to 12:30 PM, however, he got out of the scene so nursing staff could take care of the situation. The ADM stated Resident 1's fish allergy was indicated in the electronic medical records; however, the DS did not indicate the fish allergy on Resident's 1 meal ticket. The ADM stated the incident could have been avoided if the DS checked the electronic medical records for Resident 1's food allergy and indicated the fish allergy on the meal ticket correctly. The ADM stated the DS's employment was terminated from the facility. During a telephone interview on 12/5/2023 at 4:12 PM, LVN 2 stated he worked on 12/1/2023 during the 7 AM to 3 PM shift at Station 1. LVN 2 stated that at around 12:20 PM, CNA 1 called him for help because Resident 1 was having difficulty breathing. LVN 2 stated Resident 1 told him she was having a hard time breathing because she ate fish. LVN 2 stated Resident 1 told him she was allergic to fish when he arrived in Resident 1's room. LVN 2 stated the fish came from the resident's lunch tray, but he did not know Resident 1 was allergic to fish until he checked the electronic medical records. LVN 2 stated Resident 1's oxygen saturation was around 80%. LVN 2 stated he called RN 1 to assess Resident 1. LVN 2 stated he administered oxygen, elevated Resident's 1 head of the bed and rechecked Resident's 1 oxygen which was around 90% at that time. LVN 2 stated that he and RN 1 checked Resident 1's tray earlier that morning however, Resident 1's Meal Ticket did not indicate fish allergy. During an interview on 12/6/2023 at 10:06 AM, CNA 2 stated she worked on 12/1/2023, during the 7 AM to 3 PM shift and was assigned in Station 1. CNA 2 stated that on 12/1/2023, she checked Resident 1's lunch meal tray accuracy and delivered the tray to Resident 1. CNA 2 stated Resident 1's meal ticket indicated Resident's 1 name, room number but did not indicate food allergies and food dislikes. CNA 2 stated she saw a food that looked like it was fried and breaded and mixed vegetables on Resident 1's lunch tray, but unable to tell what it was. During a telephone interview on 12/6/2023 at 11:53 AM, the Dietary Supervisor (DS) stated the facility's process of communicating food allergies to the facility's kitchen. The DS stated that nursing staff would give a nursing communication slip (Dietary Communication Slip) which contained the resident's name, diet order and any known food allergies to the kitchen staff. The DS stated that after the receipt of the Dietary Communication Slip, he would visit the residents to obtain their food preferences. The DS stated, the Dietary Communication Slip did not always indicate the food allergies of the residents. The DS stated that during off hours (time when kitchen was closed), the nurses would leave the Dietary Communication Slip in a box outside the kitchen door. The DS stated the kitchen staff served fish on 12/1/2023 for lunch meals. The DS stated he was not aware that Resident 1 was allergic to fish because the Dietary Communication Slip only indicated Resident 1's name and diet. The DS stated the Dietary Communication Slip did not indicate Resident 1 had food allergy to fish. The DS could not remember if he checked Resident 1's Allergy Report found in the resident's electronic medical records. The DS stated he gave the original Dietary Communication Slip that did not indicate Resident 1's food allergy to fish, to the DSD, on 12/1/2023, after Resident 1 had the allergic reaction. During an interview on 12/6/2023 at 3:44 PM, with Resident 1's attending physician (Physician 1), Physician 1 stated he was Resident 1's primary physician. Physician 1 stated he was notified on 12/1/2023 at around 1:30 PM via text message from the facility's phone that Resident 1 had been transferred to the acute hospital (GACH 2) and Epinephrine had been administered by the facility staff. Physician 1 stated he was not notified by the facility staff before Resident 1 was transferred to GACH 2. Physician 1 stated he did not know who sent him the text message from the facility's phone because it did not indicate the name of who sent the text message. Physician 1 stated he did not know what happened to Resident 1 but was informed by facility staff afterwards, that Resident 1 was allergic to fish and ate fish on 12/1/2023. During an interview and concurrent record review on 12/6/2023 at 4:48 PM, LVN 3 stated she was the admitting nurse who admitted Resident 1 to the facility. LVN 3 stated she could not remember why she put Resident 1's Allergy Report severity as unknown and allergy manifestation as blank on Resident 1's Allergy Report. LVN 3 stated she forgot to include Resident 1's fish allergy in the Diet Communication Slip. LVN 3 stated that on 11/20/2023, upon Resident 1's admission to the facility, she saw that Resident 1 was allergic to fish upon review of Resident 1's GACH 1 record but did not see Resident 1's (allergy) severity reaction. LVN 3 stated she was busy that night (11/20/2023) when she admitted Resident 1 and must have overlooked, putting down Resident 1's allergies on the Diet Communication Slip provided to the kitchen. LVN 3 stated she should have put Resident1's allergies on the Diet communication slip so that the Kitchen staff and DS would know Resident 1 had fish allergies. During a telephone interview on 12/7/2023 at 4:08 PM, RN 1 stated that on 12/1/2023 at around 12:30 PM, LVN 2 called an overhead page regarding Resident 1 needing help. RN 1 stated Resident 1 was sitting on her bed, had watery eyes, and swollen face, particularly around the eyes. RN 1 stated Resident 1 had signs of difficulty of breathing because she was moving her hands towards her neck. RN 1 stated Resident 1's oxygen saturation was at 88%. RN 1 stated he asked CNA 1 to grab the oxygen tank and administered Resident 1 oxygen. RN 1 stated the CM told him that she spoke to Physician 1 and Physician 1 ordered to administer epinephrine and call 911. RN 1 stated he administered epinephrine to Resident 1's left thigh at around 12:32 PM. RN 1 stated that the epinephrine had no effect to Resident 1 as Resident 1 was still having shortness of breath. RN 1 stated that at that time, Resident 1 was not really talking as compared to the time when he initially got in her room. RN 1 stated LVN 2 performed CPR to Resident 1. RN 1 stated the paramedics took Resident 1 to GACH 2 at around 1 PM. During the same interview, on 12/7/2023 at 4:08 PM, RN 1 stated he was not aware that Resident 1 was allergic to fish. RN 1 stated he was the one who checked Resident 1's food tray against the Diet Type Report prior to lunch. RN 1 stated the Diet Type Report did not indicate Resident 1's food allergies. RN 1 stated Resident 1's meal ticket indicated NKFA (No Known Food Allergy) that was why the CNA handed the tray with fish to Resident 1. During a telephone interview on 12/7/2023 at 5:39 PM, with Resident 1's representative (Family 1), Family 1 stated the facility staff was aware of Resident 1's fish allergies prior to Resident 1's death on 12/1/2023. Family 1 stated she had visited Resident 1 in the facility, in the late afternoon of 11/24/2023. Family 1 stated she was in the room with Resident 1 when a CNA (unknown) brought in Resident 1's dinner. RP 1 stated she saw the dinner tray contained what appeared to be Tuna (food containing fish). Family 1 stated she asked the CNA if the tray she was bringing contained tuna because Resident 1 was allergic to fish. Family 1 stated the CNA confirmed it was tuna. RP 1 stated she told CNA 1 to immediately remove the dinner tray because Resident 1 was severely allergic to fish. Family 1 stated right after the CNA left with the dinner tray, she informed a licensed nurse of the incident and informed LVN 1 that Resident 1 could not eat fish because she was severely allergic to it. Family 1 stated LVN 1 assured her he would inform the dietary (kitchen) staff about Resident 1's fish allergy. Family 1 stated Resident 1 had been confused since admission to the facility. Family 1 stated if Resident 1 was not confused she would not have eaten the fish because Resident 1 knew she was allergic to fish. During an interview on 12/7/2023 at 6:50 PM, LVN 1 stated he worked on 11/24/2023. LVN 1 stated he could not remember if speaking to Resident 1's family on 11/24/2023. LVN 1 stated he did not remember Resident 1's Family 1 speaking to him about Resident 1 being served Tuna salad and Resident 1's fish allergy. LVN 1 stated if he was notified of Resident 1's fish allergy on 11/24/2023 by Family 1 he would have reported to the kitchen staff or Dietary supervisor. A review of the facility's Fall Menu dated 11/20/2023 to 11/26/2023, indicated the menus served to the residents on 11/24/2023, for dinner included Cream of mushroom soup, Dill Tuna Salad Sandwich, Potato chips and fruit. 2. During an interview with Resident 2, on 12/5/2023 at 9:24 AM, Resident 2 stated she was allergic to eggs, milk, wheat, sour food, and spicy food. Resident 2 stated she vomited blood and had blood in her bowel movement when she eats sour and spicy food; however, she does not remember what her allergic reactions to eggs, milk, and wheat. During the tray line observation and record review on 12/5/2023 at 11:58 AM, the diet meal ticket for Resident 2 was reviewed. The diet meal ticket indicated Resident 2 was on NAS, regular with thin liquid and included allergies to egg, wheat, shrimp, tomato, orange juice, pork, beef, and milk. A review of Resident 2's admission Record indicated the facility initially admitted the resident on 9/25/2017, and readmitted the resident on 9/13/2022, with diagnoses that included unspecified severe protein-calorie malnutrition (lack of protein and calorie in the diet causing weight and muscle loss), hypertensive heart disease with heart failure (a group of medical condition resulting from unmanaged high blood pressure) and anemia (a condition which the body does not have enough health red blood cells). A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 needed set up only and clean-up assistance when eating. A review of Resident 2's Physician diet order, dated 12/3/2023, indicated Resident 2's diet was NAS regular texture. The diet order indicated Resident 2 was allergic to egg, shrimp, tomato, orange juice, pork, beef, wheat, and milk. A review of Resident 2's care plan titled Allergies dated 6/21/2022, indicated Resident 2 had a Potential allergic reaction related to resident is allergic to: aspirin (medication is used to reduce fever and relieve minor to moderate pain), azithromycin (antibiotic that fights bacteria), eggs, milk and milk products, shrimp, wheat, beef, tomato, pork, orange juice. The care plan indicated Resident 2's allergic reaction was rash per a family member. The care plan goals indicated the resident will have no allergic reaction daily . A review of the facility's diet list (a list contained resident's name, diet and allergies used to check against resident's tray) titled Diet Type Report dated 12/5/2023, indicated, Resident 2's diet was NAS, regular texture and Resident 2's allergies included egg, shrimp, tomato, orange[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure meals did not contain food allergens (a substance that causes an allergic reaction) for two (2) of 2 sampled residents (Residents 1 and 2) with known food allergies, in accordance with the facility's policy and procedures titled Food Allergies and Reference Sheets, by: 1. Serving fish and fish containing products to Resident 1 who was allergic to fish. The facility was aware Resident 1 had fish allergy but Resident 1 was served fish on 11/24/2023 (tuna salad sandwich) and 12/1/2023 (lemon ginger fish). 2. Serving wheat (a cereal that yields a fine white flour used chiefly in breads, baked goods, and pastas) containing foods to Resident 2 who was allergic to wheat. On 12/5/23, during a lunch tray line (an area used to dish out resident's food) observation, kitchen staff served triple fruit crisp and garlic white bread that contained wheat to Resident 2. The facility was aware Resident 2 was allergic to wheat. 3. Ensuring the facility had a system in place for facility staff (licensed nurses, certified nurse assistants, dietary supervisor, kitchen staff) to implement the facility's policy and procedure titled Food Allergies and Reference Sheets, by making sure the ingredient list of foods was reviewed and recipes served to residents, which included fish for Resident 1 and wheat for Resident 2, were followed to verify that the items and meals prepared were truly allergen free. 4. Ensuring facility staff check Residents 1 and 2's meal tickets for accuracy, and food allergens as indicated in residents' electronic medical records, in accordance with the facility's policy and procedure titled Diet Record Maintenance. As a result of this deficient practice, Resident 1 had an allergic reaction on 12/1/2023, after eating fish for lunch. Resident 1 had difficulty breathing and was observed with watery eyes and swollen face. The facility's licensed nurses called 911 emergency medical services (EMS), EMS intubated (healthcare provider inserts a tube through person's mouth or nose down to their airway) Resident 1 and administered two doses of epinephrine (used in emergencies to treat very serious allergic reactions). Resident 1 passed away upon arrival to the General Acute Care Hospital (GACH) 2 emergency room (ER) due to anaphylaxis (severe allergic reaction including closure of airways). This deficient practice had the potential to cause life-threatening conditions such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (heart stops beating suddenly) and death for Resident 2. On 12/5/2023 at 7 PM, while onsite at the facility, the Director of Nursing (DON) and the Administrator (ADM) were verbally notified of an Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) situation regarding food and nutrition services. Resident 1, who was identified as having food allergies to fish was served fish on 11/24/2023 and 12/1/2023. Resident 2, who was identified as having food allergy to wheat was served wheat on 12/1/2023. On 12/07/2023 at 7:11 PM, the IJ was removed in the presence of the ADM, DON, Registered Dietitian (RD) 1, Nursing Consultant 1 (NC 1) and NC 2 after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified and confirmed onsite the facility's implementation of the IJ Removal Plan. 1. Registered Dietitian 1 (RD 1) educated Resident 2 about avoiding food that she was allergic to minimize adverse reaction. RD 1 reviewed all residents' meals served on 12/6/2023 to ensure accuracy on meals served for breakfast prior to distribution of trays to the residents. RD 1 observed dietary staff during meal preparation on 12/6/2023 for breakfast, lunch and dinner to ensure tray accuracy before the trays were served to the residents. RD 1 in-serviced nursing staff on 12/6/2023, about wheat allergy and wheat containing foods. 2. RD 1 conducted training with dietary staff on 12/6/2023, including aides and cooks regarding diet communication form processing, meal ticket creation, meal preparation following recipes and spreadsheet, tray line process and food allergies. RD 1 conducted interviews with all residents with food allergies and food preferences to ensure accuracy of allergies transcribed on the meal tickets based on Residents medical records. 3. The DON provided education to LVNs (Licensed Vocational Nurses) and Certified Nursing Assistants (CNA) on 12/6/2023, regarding food allergies, meal tray verification and tray accuracy. 4. The DON audited the Nutritional Care plans to ensure that allergies and allergic reactions of all residents with known allergies are entered in the care plans. 5. The DON provided in-service education to LVN 3 who admitted Resident 1 on 11/20/2023, regarding completion of dietary communication of diet orders and restrictions, allergies with the kitchen staff. The DON and Director of Staff Development (DSD) provided in-service on 12/1/2023 to LVNs regarding the process of communication of diet orders, restrictions, allergies to the kitchen. 7. The Regional Dietitian provided education on 12/4/2023, 12/5/2023 and 12/6/2023 to Cooks and Dietary Staff on the following: Diet Communication Form Processing, Meal ticket creation, meal preparation following the recipe and spreadsheet, tray line process and food allergies. 8. The Regional Dietitian updated Resident 2's dietary profile and care plan on 12/5/2023 for food preferences, food allergies and meal tray ticket. The Regional Dietitian reverified Resident 2's food allergies and updated Resident 2's meal tray ticket indicating the food allergies of Resident 2 according to the Dietary Profile. 9. Resident 2's physician placed an order for Resident 2 to obtain an allergy test determining allergy severity and reactions to wheat. The physician will notify Resident 2 and her family upon the receipt of the allergy test. 10. Licensed Nurses and RD 1 revised Resident 2's Nutritional Comprehensive Care Plan on 12/6/2023 based on Resident 2's dietary interview. 11. The facility designee conducted a meal tray verification learning validation testing on 12/7/2023 to the two LVNs and CNAs who verified Resident 2's meal tray on 12/5/2023. 12. The DON, designee and dietary manager reviewed and audited 99 current diet orders, allergies, tray cards on 12/1/2023 to ensure all dietary allergies were reflected on resident's records. 13. The DON and designee conducted rounds and observations of current residents and assessed if any residents were exhibiting signs and symptoms of allergic reactions. 14. The Regional Dietitian conducted a second audit of the diet orders, dietary profiles and meal ticket to ensure diet restrictions, preferences and food allergies are accurately entered in the system. No other residents were identified. 15. The DON reported to the attending physician of four (4) other residents who had no history or were unable to recall allergic reactions. Attending physician ordered an allergy test. The facility drew an allergy test on 12/6/2023 to the 4 residents. The attending physician will notify the resident and family of the allergy test. 16. The Regional Dietitian audited and observed the following on 12/6/2023 - Conducted skill competency validation to the dietary staff regarding transcription of dietary orders, restrictions, food preferences, and allergy information into the Resident Dietary System (RDS) to generate accurate meal tickets. - Observed dietary staff during the meal preparation for breakfast, lunch, and dinner. - Observed tray line service for breakfast, lunch, and dinner for tray accuracy prior to placing the meal trays in the meal cart. 17. The Regional Dietitian provided in-service education to nursing staff on wheat allergen and food to avoided. 18. The Regional Dietitian will orient, train, and conduct competency regarding dietary policies and procedures, diet communication from processing meal ticket, RDS system, meal preparation, tray line, food allergies, dietary profile, and care plan development once the Dietary Manager was hired. 19. The facility implemented of the new process on how to handle food allergy on 12/7/2023: The dietary manager will conduct an audit of current diet orders, diet order and communication forms, food allergies, meal tray ticket from the RDS system, dietary profile, and care plan weekly for 4 weeks then bi-monthly for 2 months to ensure accuracy of diet of residents. Cross referenced to F684. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 11/20/2023, with diagnoses that included Type 2 diabetes mellitus (DM, a health condition when the body does not use insulin properly causing increase in blood sugar), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), and essential hypertension (high blood pressure). A review of Resident 1's Minimum Data Sheet (MDS, a standard assessment tool that measures health status), dated 11/27/2023, indicated the resident's cognition (a mental process that take place in the brain, including thinking, attention, language, learning, memory, and perception) was severely impaired. The MDS indicated Resident 1 needed partial/moderate (helper does less than half of the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort) assistance when eating. A review of Resident 1's physician diet order, dated 11/20/2023, indicated Resident 1's diet was No Added Salt (NAS, no salt packet on the tray) consistent carbohydrates (CCHO, the same amount of carbohydrate served each meal), regular texture, thin consistency. A review of Resident 1's Order Summary Report, for December 2023, signed by Physician 1 on 11/21/2023, indicated Allergies: fish. A review of Resident 1's GACH 1 History and Physical (H&P, details of physician examination of the resident), dated 11/10/2023, indicated, Resident 1's allergic reaction to fish was anaphylactic reaction. A review of Resident 1's Allergy Report printed by the facility with created date 11/20/2023 indicated Resident 1 had a food allergy and the allergy was Fish. The Allergy Report severity indicated unknown. The Allergy Report indicated blank on Reaction Manifestation and blank on Reaction Note. A review of the facility's fall menu spreadsheet dated 12/1/2023, approved by RD 2 on 8/17/2023 indicated, CCHO, NAS diet included the following food item on the tray: Lemon ginger fish 3 ounces (oz, a unit of measurement) A review of the facility's recipe titled Lemon-Ginger Fish not dated, indicated ingredients included: fish fillet, thawed (suggest tilapia, pangasius-swai, cod), ginger, jarred or ginger, ground, melted margarine, lemon juice and salt. A review of Resident 1's progress notes from 11/07/2023 to 12/08/2023, with a note titled SBAR [Situation, Background, Assessment and Recommendations] Summary for Providers dated 12/01/2023 signed by Registered Nurse (RN) 1 timed at 12:30 PM indicated, At 12:15 PM, Certified Nursing Assistant (CNA 1) served lunch plate to Resident 1. Around 12:25 PM, the resident called the CNA and complained of shortness of breath. CNA (CNA 1) called LVN (LVN 2), and he paged Registered Nurse 1 (RN 1) to assess Resident 1 around 12:26 PM. Resident 1 was assessed at 12:28 PM, Resident 1's Oxygen saturation (amount of oxygen circulating in the blood) was at 88% (normal oxygen saturation: 95 to 100%). RN 1 administered oxygen 2 liters via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen level) and elevated the resident's head of bed. Oxygen saturation was rechecked, and it was 91%. RN 1 asked Case Manager (CM) to call Resident 1's physician around 12:30 PM. (Physician 1) ordered epinephrine 1 mg via intramuscular (under the muscle) injection and to call 911 emergency service. LVN 1 was delegated to call 911 around 12:31 PM. Around 12:32 PM, epinephrine was administered to left thigh of Resident 1 but no effect. No vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body function) appreciated (found or noted) around 12:35 PM. CPR (cardiopulmonary resuscitation [an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped]) initiated and 911 (EMS) came around 12:38 PM and took over to continue CPR and resident was taken to (GACH 2) around 1 PM. During an interview on 12/5/2023 at 9:15 AM, CNA 1 stated she worked on 12/1/2023 during the 7 AM to 3 PM shift and was assigned to Station 1 and to Resident 1. CNA 1 stated on 12/1/2023 at around 12:30 PM, she responded to Resident 1's call light and upon CNA 1's entrance to Resident 1's room, Resident 1 verbalized to her that she was having an allergic reaction to fish. CNA 1 stated, Resident 1 appeared to have shortness of breath. CNA 1 stated she ran out of Resident 1's room to get the oxygen tank and informed LVNs 1 and 2, who both attended to Resident 1. CNA 1 stated the kitchen staff served fish that looked like tilapia to Resident 1 for lunch. CNA 1 stated Resident 1 ate the whole fish. CNA 1 stated, she was aware that Resident 1 was allergic to fish and seafood but unsure of the allergic reaction. CNA 1 could not recall who passed Resident 1's lunch tray on 12/1/2023. During an interview on 12/5/2023 at 10:46 AM, with LVN 1, LVN 1 stated he worked on 12/1/2023 during the 7 AM to 3 PM shift as a desk nurse. LVN 1 stated on 12/1/2023, at around lunch time, he observed Resident 1 coughed, held her neck with swollen face, and watery eyes. LVN 1 stated the fish came from Resident 1's tray served by the facility's kitchen. During an interview on 12/6/2023 at 10:06 AM, CNA 2 stated she worked on 12/1/2023, during the 7 AM to 3 PM shift and was assigned in Station 1. CNA 2 stated that on 12/1/2023, she checked Resident 1's lunch meal tray accuracy and delivered the tray to Resident 1. CNA 2 stated Resident 1's meal ticket indicated Resident's 1 name, room number but did not indicate food allergies and food dislikes. CNA 2 stated she saw a food that looked like it was fried and breaded and mixed vegetables on Resident 1's lunch tray, but unable to tell what it was. CNA 2 stated that the process of passing the meal trays to the residents were as follows: (1) Two licensed nurses checked each resident's tray in the hallway from the kitchen against a list (Diet Type Report (a list of residents, their corresponding diets and other information such as allergies) for diet accuracy, consistency of food, food preferences, food likes and dislikes and food allergies. Once the licensed nurse checked the resident's tray, the licensed nurse passed the meal trays to the CNAs to deliver to the resident's room. (2) CNAs checked the meal ticket on the trays for resident's name, room number, allergies, dislikes, and food that the residents were supposed to be getting before giving it to the residents. If the meal trays were inaccurate, CNAs would not pass the trays to the residents and report it to the licensed nurse. During an interview on 12/5/2023 at 3:44 PM, the DON stated RN 1 and LVN 2 administered oxygen while Resident 1 was having shortness of breath. The DON stated Resident 1 ate fish that came from the facility's kitchen during lunch meal on 12/1/2023. The DON stated that based on their investigation, RN 1 and LVN 2 checked Resident 1's meal tray for accuracy and Resident 1's meal ticket did not indicate Resident 1 was allergic to fish. The DON stated the Dietary Supervisor (DS) did not indicate Resident 1's allergy to fish on the resident's meal ticket. The DON stated the DS could not say if he checked Resident 1's electronic medical records to confirm. The DON stated Resident 1 passed away on 12/1/2023. During an interview on 12/5/2023 at 4 PM, the ADM stated that on 12/1/2023, he had witnessed Resident 1's change of condition (allergic reaction) around 12:15 PM to 12:30 PM, however, he got out of the scene so nursing staff could take care of situation. The ADM stated Resident 1's fish allergy was indicated in the electronic medical records; however, the DS did not indicate the fish allergy on Resident's 1 meal ticket. The ADM stated the incident could have been avoided if the DS checked the electronic medical records for Resident 1's food allergy and indicated the fish allergy on the meal ticket correctly. The ADM stated the DS's employment was terminated from the facility. During a telephone interview on 12/5/2023 at 4:12 PM, LVN 2 stated he worked on 12/1/2023 during the 7 AM to 3 PM shift at Station 1. LVN 1 stated that at around 12:20 PM, CNA 1 called him for help because Resident 1 was having difficulty breathing. LVN 2 stated Resident 1 told him she was having a hard time breathing because she ate fish. LVN 2 stated Resident 1 told him she was allergic to fish when he arrived in Resident 1's room. LVN 2 stated the fish came from the resident's lunch tray, but he did not know Resident 1 was allergic to fish until he checked the electronic medical records. LVN 2 stated, on 12/1/2023, at approximately around 12:25 PM, Resident 1's oxygen saturation was around 80%. LVN 2 stated that he and RN 1 checked Resident 1's tray earlier that morning however, Resident 1's meal ticket did not indicate fish allergy. During a concurrent interview on 12/5/2023 at 6:11 PM, with Nursing Consultant (NC) 1 and a record review of Resident 1's profile in the electronic medical records, Resident 1's profile indicated Resident 1 was allergic to fish written in red font. During a telephone interview on 12/6/2023 at 10:59 AM, the Director of Staff Development (DSD) stated that residents who have known allergies, the specific allergies were written in red and those residents with no known food allergy, would indicate NKFA on their meal tickets. During an interview on 12/6/2023 at 11:15 AM, the CM stated she went to Resident 1's room when she heard Resident 1 needed help on 12/1/2023 at approximately around 12:30 PM. The CM stated she saw Resident 1 had an oxygen mask and struggling to breathe. The CM stated she observed Resident 1 had a swollen face. The CM stated she was aware that Resident 1 was allergic to fish and called 911 emergency medical services (EMS). During a telephone interview on 12/6/2023 at 11:53 AM, the Dietary Supervisor (DS) stated the facility's process of communicating food allergies to the facility's kitchen. The DS stated that nursing staff would give a nursing communication slip which contained the resident's name, diet order and any known food allergies to the kitchen staff. The DS stated that after the receipt of the nursing communication slip, he would visit the residents to obtain their food preferences. The DS stated, the nursing communication slip did not always indicate the food allergies of the residents. The DS stated that during off hours (time when kitchen was closed), the nurses would leave the nursing communication slip in a box outside the kitchen door. The DS stated the kitchen staff served fish on 12/1/2023 for lunch meals. The DS stated he was not aware that Resident 1 was allergic to fish because the nursing communication slip only indicated Resident 1's name and diet. The DS stated the nursing communication slip did not indicate Resident 1 had food allergy to fish. The DS could not remember if he checked Resident 1's Allergy Report found in the resident's electronic medical records. The DS stated he gave the original nursing communication slip that did not indicate Resident 1's food allergy to fish, to the DSD, on 12/1/2023, after Resident 1 had the allergic reaction. During a telephone interview on 12/7/2023 at 4:08 PM, RN 1 stated that on 12/1/2023 at around 12:30 PM, Resident 1 was sitting on her bed, had watery eyes, and swollen face, particularly around the eyes. RN 1 stated Resident 1 had signs of difficulty of breathing because she was moving her hands towards her neck. RN 1 stated that the epinephrine he administered to the resident had no effect as Resident 1 was still having shortness of breath. RN 1 stated LVN 2 performed CPR on Resident 1. RN 1 stated the paramedics ([or EMS -Emergency Medical Services] a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) took Resident 1 to GACH 2 at around 1 PM. RN 1 stated he was not aware that Resident 1 was allergic to fish. RN 1 stated he was the one who checked Resident 1's food tray against the Diet Type Report prior to lunch. RN 1 stated the Diet Type Report did not indicate Resident 1's food allergies. RN 1 stated Resident 1's meal ticket indicated NKFA (No Known Food Allergy) that was why the CNA handed the tray with fish to Resident 1. During an interview on 12/7/2023 at 5:39 PM with Resident 1's representative (Family 1), Family 1 stated the facility staff was aware of Resident 1's fish allergies prior to Resident 1's death on 12/1/2023. Family 1 stated she visited Resident 1 in the late afternoon of 11/24/2023. Family 1 stated she was in the room with Resident 1 when a CNA (unknown) brought in Resident 1's dinner. RP 1 stated she saw the dinner tray contained what appeared to be Tuna (food containing fish). Family 1 stated she asked the CNA if the tray she was bringing contained tuna because Resident 1 was allergic to fish. Family 1 stated the CNA confirmed it was tuna. RP 1 stated she told CNA 1 to immediately remove the dinner tray because Resident 1 was severely allergic to fish. Family 1 stated right after the CNA left with the dinner tray, she informed a licensed nurse of the incident and informed LVN 1 that Resident 1 could not eat fish because she was severely allergic to it. Family 1 stated LVN 1 assured her he would inform the dietary (kitchen) staff about Resident 1's fish allergy. A review of the facility's Fall Menu dated November 20 to 26, 2023, indicated the menu served to the residents on 11/24/2023, for dinner, included Cream of mushroom soup, Dill Tuna Salad Sandwich, Potato chips and Fruit. A review of Resident 1's GACH 2 records dated 12/1/2023 titled ED Provider Notes authored by the ED Physician, indicated (Resident 1) was brought in from the (facility) where the resident was in cardiac arrest, CPR for 18 minutes. The ED Physician wrote that according to the paramedics, 3 (three) epinephrine were given and Resident 1 lost pulses and ED Physician immediately intubated Resident 1. The ED Physician wrote Resident 1 was given another epinephrine and CPR was continued until the ultrasound (an imaging method that uses sound waves to produce images of structures within the body) showed no heart movement at 1:53 PM. At 2:06 PM, Resident 1 was defibrillated (use of electrical current to help a person's heart return to normal rhythm) in the ED and there was no change in heart movement at 2:06 PM. The ED Physician wrote Diagnosis Death secondary to cardiac arrest with severe metabolic (a condition in which acids build up in the body) and respiratory acidosis (occurs when the blood is too acidic due to high levels of carbon dioxide [the gas formed when carbon is burned, or when people or animals breathe out). The ED Physician further wrote that he spoke to Resident 1's attending physician, Physician 1, who stated Resident 1 was allergic to fish and she was given fish. 2. A review of Resident 2's admission Record indicated the facility initially admitted the resident on 9/25/2017, and readmitted the resident on 9/13/2022, with diagnoses that included unspecified severe protein-calorie malnutrition (lack of protein and calorie in the diet causing weight and muscle loss), hypertensive heart disease with heart failure (a group of medical condition resulting from unmanaged high blood pressure) and anemia (a condition which the body does not have enough health red blood cells). A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 needed set up only and clean-up assistance when eating. A review of Resident 2's Physician diet order, dated 12/3/2023, indicated Resident 2's diet was NAS regular texture. The diet order indicated Resident 2 was allergic to egg, shrimp, tomato, orange juice, pork, beef, wheat, and milk. During an interview with Resident 2, on 12/5/2023 at 9:24 AM, Resident 2 stated she was allergic to eggs, milk, wheat, sour food, and spicy food. Resident 2 stated she vomited blood and had blood in her bowel movement when she eats sour and spicy food; however, she does not remember what her allergic reactions to eggs, milk, and wheat. During the tray line observation and record review on 12/5/2023 at 11:58 AM, the diet meal ticket for Resident 2 was reviewed. The diet meal ticket indicated Resident 2 was on NAS, regular with thin liquid and included allergies to egg, wheat, shrimp, tomato, orange juice, pork, beef and milk. A review of the facility's diet list (a list contained resident's name, diet and allergies used to check against resident's tray) titled Diet Type Report dated 12/5/2023, indicated, Resident 2's diet was NAS, regular texture and Resident 2's allergies included egg, shrimp, tomato, orange juice, pork, beef, wheat and milk. A review of the facility's diet manual titled Gluten-Restricted Diet (a type of protein naturally found in wheat, grains, barley and rye), (not dated) indicated, This diet eliminates all foods containing wheat. List of foods to avoid included bread, rolls, cookies, cakes or pies prepared with prohibited flours. During the tray line observation at the facility's hallway, on 12/5/2023 at 12:50 PM, Resident 2's diet meal ticket indicated Resident 2's allergies included egg, wheat, shrimp, tomato, orange juice, pork, beef and milk as allergies . Resident 2's meal tray consisted of mashed potatoes, fried chicken, triple fruit crisp, garlic white bread, soup, cranberry juice and water. During the meal tray checking observation by licensed nurses on 12/5/2023 at 1:02 PM, RN 2 and the Infection Preventionist Nurse [IPN] checked Resident 2's lunch tray against the Diet Type Report. During the observation, RN 2 read Resident 2's name, diet, allergies to egg, wheat, shrimp, tomato, orange juice, pork, beef and milk while IPN checked the diet meal ticket and foods on Resident 2's tray. The IPN handed Resident 2's meal tray containing wheat without any corrections. At this time, the State Agency (SA) intervened and alerted the facility staff to remove the tray being served to Resident 2 because the meal being served contained wheat. A review of the facility's recipe titled Garlic Bread (not dated), indicated Ingredients included garlic powder, melted margarine, parsley flakes, wheat bread of soft French bread. Serve 1 corn tortilla with 1 tsp margarine for gluten free diet. A review of the facility's recipe titled Triple Fruit Crisp not dated, indicated Ingredients included diced pears, diced peaches, canned crushed pineapple, lemon juice, cinnamon, softened margarine, all-purpose flour, uncooked rolled oats, and brown sugar. Serve mix fruit topped with gluten free whipped cream for gluten free diet. During a concurrent observation of Resident 2's lunch meal tray on 12/5/2023 at 1:14 PM, in Resident 2's room and an interview with RD 1 and Resident 2, RD 1 stated, Resident 2 should have not been given bread nor granola in her tray and replaced the tray with a wheat free tray. RD 1 stated the possible outcome to Resident 2, who received food items that they were allergic to were allergic reactions such as rash, anaphylactic shock, and death. Resident 2 stated she was hungry and wanted to eat the bread, but she was told and tested in the past that she was allergic to wheat and did not know her allergic reaction if she ever ate wheat. Resident 2 stated that she was not aware what foods contained wheat and questioned if she was supposed to have had bread on her tray because of her wheat allergy. During an interview on 12/7/ 2023 at 8:24 AM, the IPN stated that the facility's process of checking the resident's meal trays was to have two licensed nurses check the Diet Type Report against the diet meal ticket and the meal tray. After the 2 licensed nurses checked the meal for accuracy, they would hand the meal trays to the CNAs. The CNAs would recheck the meal trays for accuracy prior to serving to the residents. The IPN stated that on 12/5/2023, he was the one who checked Resident 2's trays and RN 2 was holding the Diet Type Report. The IPN stated he checked everything on Resident 2's meal tray, diet meal ticket and read that Resident 2 was allergic to wheat; however, he did not know that the garlic white bread contained wheat. The IPN stated the possible outcome for Resident 2 who consumed foods that she was allergic to was anaphylactic shock, enlarge tonsils (either of a pair of prominent masses of tissues that lie one on each side of the throat) causing inability to breath and cardiac arrest. During an interview on 12/7/2023 at 3:35 PM, RD 2 stated that the DS was the one who interviewed residents for food allergies and food preferences and that food allergies and preferences auto populate (data that is being inputted or entered were auto filled in every field in a form) in the dietitian's assessment for the residents. RD 2 stated they do not repeat or re-interview residents for food allergies. RD 2 stated it was important to have a system in place and have accurate allergy records for the residents because it could lead to different type of reactions including rashes and anaphylactic shock for those residents who consumed food that they were allergic to. A review of the facility's policy and procedure titled Diet Record Maintenance revised on 6/10/2014 and approved by Quality Improvement Committee (QIC) on 1/31/2023, indicated The diet record will contain the following information to be reflected on the resident's tray card: (g) allergies. A review of the facility's policy and procedure titled Diet Identification Card revised on 4/21/2012 and approved by QIC on 1/31/2023, indicated To ensure the resident receives the proper diet as ordered by the physician. II. Additional information available on the diet identification card should be completed for each resident. Additional information may include, food preferences, beverage, dining location and level of assistance. A review of the facility's diet manual titled Food Allergies and Reference Sheets, not dated, indicated Food allergies may produce adverse, sometimes life threatening, effects and eliminating the allergy causing food is the only way for residents to avoid a reaction. It is important that the resident's entire care team is made aware of the food allergy and its reaction. Special consideration must be taken within the facility kitchen, as well as any foods being brought in from outside sources for residents. The avoidance of cross contamination within the facility's kitchen is key when preparing food for residents with food allergies. This means that safe, non-allergic food must not come in contact with other potential allergenic foods within only step of the foodservice preparation and delivery. General considerations included reviewing ingredient list of foods used and recipes followed to verify that the items and meals prepared are truly allergen free. A review[TRUNCATED]